Sadik Miah · Prevention of Future Deaths report

On 19th October 2011, I opened an inquest into the death of Sadik Miah, case ref 2654-11, date of birth 17 May 1968, date of death 15th October 2011. The inquest was heard on 4th June 2014. The conclusion of the inquest was given by a narrative verdict below.

Mr Miah suffered from schizophrenia and did not have insight into his psychosis, for which he needed to and did take Olanzapine 15mg daily. He was detained under the MHA in Lambeth Hospital for his safety, to manage his psychogenic polydipsia. On 15th October 2011, he collapsed suddenly and appropriate resuscitation did not prevent his death. He had a sudden cardiac death, which is recognised as a characteristic of schizophrenia and on the balance of probabilities the antipsychotic medication was a contributory factor to death, which occurred at 16.46 on 15/10/11 in Lambeth Hospital

During the inquest it was heard that antipsychotics, including Olanzapine, may cause arrhythmias and that a cardiologist's opinion may be needed from time to time. In this case the ECG done available was done in 2010 and showed a prolonged QT interval of 440, prior to transfer. ████████ said that he had an ECG in A&E but that this was not monitored by psychiatrists.

During the inquest evidence was heard that he developed hyponatraemia from excessive drinking but the aetiology was not clear, although he was thought to have psychogenic polydipsia. A referral was made to an endocrinologist for a routine out patient appointment, for which there would be a 6-12 week wait. One of the possibilities of the cause was that it was medication related and it was agreed that such a delay was not appropriate. The court heard that there was a facility for emergency treatment for a physical illness, but apparently no facility for a medical opinion that was not an emergency but should not wait several weeks.

(1) ████████ said that consultant psychiatrists caring for in-patients with physical health problems did not have the benefit of a fellow consultant physician visiting, examining and advising on management, as would occur in a DGH. This did create a risk of other deaths occurring and should be a concern for the coroner.

(2). It was reported that the Trust had been developing a Physical Health Policy and building corporate relationships, but that there was no national guidance about how organizations should address these matters. The court was not informed of the extent to which there was resolution of the areas of concern of the coroner.